Healthcare Provider Details

I. General information

NPI: 1114588761
Provider Name (Legal Business Name): ROXANNE LYNNE KRUGER MA, LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MONROE AVE NW
GRAND RAPIDS MI
49503-1445
US

IV. Provider business mailing address

552 FULTON ST E # 2
GRAND RAPIDS MI
49503-5923
US

V. Phone/Fax

Practice location:
  • Phone: 517-769-4444
  • Fax:
Mailing address:
  • Phone: 517-769-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401017416
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: